Health inspection·July 12, 2019

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and vital signs records that no OBP were documented when the fall risk assessments were done. The MDSA stated the OBP result should be documented as a basis for the response on item # 10 in the Fall Risk Assessment for any drop in systolic BP of 20 mmHg (millimeter mercury, unit of measurement) between lying and standing. A review of the facility's April 2008 revised policy, Charting and Documentation indicated all observations, medications administered, services performed, etc., must be documented in the resident's clinical record. Documentation of procedures or treatments shall include care-specific details and includes the assessment data and /or unusual findings obtained during the procedure. Entries in the resident's clinical record by licensed personnel will be recorded in accordance with state law and facility policy. Event ID: Facility ID: 056055 If continuation sheet Page 2 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2. During an observation on 7/10/19 at 2:11 p.m., Resident 2 was awake lying in bed. He stated he preferred to stay in bed except for shower days. He had some contractures in both hands and a bilateral foot drop. Resident 2 also stated he had not been getting his exercises for about a year now. Review of Resident 2's clinical record indicated he had cerebellar ataxia (a genetic disease that causes progressive loss of coordination and difficulties with balance and gait). Review of his minimum data set (MDS, an assessment tool) dated 3/12/19, indicated he was cognitively intact, and required extensive assistance from staff for his care. He also had impairment of both upper and lower extremities for range of motion (ROM). During a record review and concurrent interview with the MDSC on 7/11/19 at 1:39 p.m., she stated the contracture was noted on 2/6/14 during the quarterly MDS assessment. She confirmed there was no care plan on impairment of ROM and contractures and stated there should have developed a care plan for impaired ROM and contractures. A review of the August 2006 revised facility's policy, Comprehensive care Plans, indicated an individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. During multiple observations of the dining room on 7/8/19, 7/9/19 and 7/10/19 during lunch time, Resident 18 was in room and not in the dining room. During an observation on 7/8/19 at 12:37 p.m., Resident 18 was observed in room lying in bed with his eyes closed. During another observation on 7/9/19 at 12:40 p.m., Resident 18 was observed in his room during lunch time. Resident 18 was in bed with eyes closed. The lunch tray was in front of the Resident 18 and no staff was noted at his bedside. During another observation on 7/10/19 at 12:34 p.m., Resident 18 was observed in his room with eyes closed. Review of Resident 18's nutritional care plan indicated Resident 18 has a potential for nutritional problems due to poor dietary intake, dysphagia (difficulty swallowing), and diet restrictions. It indicated Resident 18 would eat in the restorative nursing assistant (RNA) dining room with other residents and get assistance from staff during meals. During an interview with registered nurse C (RN C) on 7/10/19 at 3:41 p.m., RN C stated Resident 18 does not get up during lunch for the RNA dining room. RN C stated Resident 18 was independent during meals and the certified nursing assistants were documenting that Resident 18 was independent on eating and only needed set-up for the tray. During an interview with the minimum data set (MDS, an assessment tool) coordinator (MDSC) on 7/10/19 at 4:00 p.m., the MDSC stated the MDS assessment on 6/10/19 indicated Resident 18 needed supervision during eating with one person physical assistance. The MDSC confirmed Resident 18's plan of care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 3 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 18 needed assisted dining with one person assistance. The MDSC stated there was no care plan indicating if Resident 18 refused food or transfer to the RNA dining room. During an interview with the registered dietician (RD) on 7/11/19 at 7:59 a.m., RD stated Resident 18 was on RNA dining. RD stated she was not aware Resident 18 was not going to the RNA dining and there was no reports from the nurses that Resident 18 was not going to the RNA dining for meal assistance. RD confirmed staff were documenting that they were only doing set-up for Resident 18. Based on observation, interview and record review the facility failed to develop and implement the plan of care for two of 18 sampled residents (Residents 18 and 2) when: 1. Nutritional care plan for Resident 18 was not implemented or revised; and 2. Care plan for range of motion (ROM) was not developed for Resident 2. These failures had the potential for not implementing the necessary residents' plan of care. Findings: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 4 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of practice for one of one resident (Resident 54), when the facility failed to provide training on the use of a rental low air loss mattress (LAL, special mattress that provide air flow to keep the skin dry and prevent pressure ulcer [injury to skin and underlying tissue resulting from prolonged pressure on the skin]. This failure could put the resident at risk for developing or worsening of a pressure ulcer. Residents Affected - Few Findings: During an observation on 7/8/19 at 1:30 p.m., with certified nursing assistant H (CNA H), Resident 54 was lying flat on her bed with her head tilted to her left side. She had contractures of both hands and bilateral heel protectors on with both feet elevated on pillows. She was on an LAL mattress. There was no light on the air mattress machine pump hanging at the foot of the bed, as it was not turned on. During a concurrent interview with CNA H, he stated he was not sure why the machine was off. He stated it should be on and then proceeded to press on the surface of the machine pump multiple times and later acknowledged he did not know how to turn the machine pump on. CNA H stated the tall guy (director of environment) was in charge of checking the machine. During a subsequent observation on 7/8/19 at 4;15 p.m., Resident 54 was lying in bed in the same position. The machine pump was not on for the LAL mattress. During a concurrent interview with licensed vocational nurse O (LVN O), she stated she did not know why the machine pump for the LAL mattress was turned off. She acknowledged she did not know how to turn it on. She stated the nurse should check at the start of the shift to ensure the LAL mattress was turned on. During an interview with the director of staff development (DSD) on 7/10/19 at 8:16 a.m., she stated the environmental service director (ESD) gave staff an in-service regarding the use of the LAL mattress during skills day. During an interview with the ESD on 7/10/19 at 9:34 a.m., he stated he gave staff an in-service about two weeks ago on the use of the LAL. However, he stated the training was on the use of the in-house LAL mattress and not on the use of the rental LAL mattress. The ESD stated he should have asked the representative from the rental company to do an in-service to the staff. Review of Resident 54's clinical record indicated she was admitted on [DATE] with the diagnoses to include multiple sclerosis (nerve damage that disrupts communication beetween the brain and the body). Resident 54's care plan indicated she was totally dependent on staff for nursing care and she had the potential for development of pressure ulcer due to her immobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 5 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an ongoing activity program one sampled resident (Resident 56). This failure had the potential to negatively affect the resident's psychosocial well-being and quality of life. Residents Affected - Few Findings: During observations of Resident 56 on 7/8/19, 7/9/19, and 7/10/19, Resident 56 was observed lying in bed with his eyes closed and the television on. Review of the Resident 56's Documentation Survey Report V2 for July 2019 indicated Resident 56's last documented social activity was on 7/4/19 for an audio and visual activity. Last room visit from activity documented was on 7/3/19. During an interview with the activity director (AD) on 7/11/19 at 10:13 a.m., the AD stated Resident 56 has not gotten out of bed for activities since re-hospitalization. The AD stated there was no in-room activities for a week for Resident 56 since 7/4/19. The AD stated AD was not available for in-room visits due to other duties in the facility and non-work related commitments. The AD also stated one of two activity assistants was on vacation and the other activity assistant available had to stay in the activity room for residents who were able to attend activities in the activity room and was not able to do room visits at the time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 6 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure two of 18 residents (63 and 18 ) received necessary care and services when: Residents Affected - Few 1. Staff failed to assess, monitor, treat Resident 63's left leg wound; 2. Staff failed to address Resident 18's new skin condition on Resident 18's great toes. These failures had the potential to affect the residents' care and jeopardize the residents' health. Findings: 1. During an observation and interview with Resident 63 on 7/8/19 at 2:32 p.m., Resident 63 stated he had a wound on the left leg. Resident 63's left leg on the shin was noted with a foam dressing. During another observation and interview with registered nurse L (RN L) on 7/12/19 at 8:47 a.m., RN L stated the wound dressing for Resident 63's left shin abrasion was ordered to be done every day. RN L confirmed the dressing on Resident 63 was dated 7/9/18. During a concurrent record review and interview with the assistant director of nursing (ADON) on 7/12/19 at 8:50 a.m., the ADON stated the treatment for Resident 63's wound on the left shin was started on 6/28/19. The ADON confirmed there was no progress notes or a change of condition done regarding Resident 63's left shin wound since it was identified. The ADON stated the Skin Condition Record for Non-Pressure Ulcer Skin Condition form for Resident 63 was incomplete and there was no documentation on wound measurements on the initial assessment on 6/28/19 and the following assessments on 7/2/19 and 7/3/19. The ADON confirmed the plan of care for Resident 63's left shin wound was created on 7/3/19, five days after the wound was identified. The ADON stated the nurses documented in the treatment administration record the left shin dressing was done on 7/10/19 and 7/11/19. A review of the facility's undated form, Facility Wound Treatment Protocols, indicated under abrasions to change the dressing daily. 2. Review of Resident 18's active physician's orders for July 2019 indicated no active orders for wound or skin breakdown. Review of Resident 18's weekly summary dated 7/5/19 indicated no skin conditions. Review of the facility's progress notes for Resident 18 did not indicate new skin conditions observed on 7/10/19. During an observation and interview with registered nurse C (RN C) on 7/10/19 at 10:35 a.m., RN C inspected Resident 18's feet and stated Resident 18 has a non-blanchable area on the tip of the left great toe. RN C also stated there was also blanchable redness on the tip of the right great toe. During an interview with RN C on 7/11/19 at 11:16 a.m., RN C stated he did not make a change of condition report regarding Resident 18's new skin conditions observed on 7/10/19. RN C also stated he did not notify the physician or the responsible party regarding the new skin issues found on 7/10/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 7 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the ADON on 07/11/19 11:27 a.m., ADON stated the nurses have to notify the physician and the responsible party regarding new skin issues. She also stated the nurses have to make a skin monitoring sheet, create a plan of care and place the resident on a 72 hours charting for monitoring. A review of the facility's undated form, Skin Breakdown (Skin tear, abrasions, excoriations, pressure injuries, rash), indicated to document in the nursing progress notes which includes notifying the physician and the responsible party and place the resident on a 72 hour charting. It also indicated to make a care plan and not to endorse to the next shift. It also indicated to complete a skin sheet. Event ID: Facility ID: 056055 If continuation sheet Page 8 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services were provided to prevent pressure injury (localized damage to the skin and underlying soft tissue usually over a bony prominence or other device) for one resident (18) when staff did not reposition Resident 18 while in bed. This failure had the potential to cause new pressure ulcers to develop. Residents Affected - Few Findings: During another observation on 7/10/19 at 8:30 a.m., Resident 18 was sitting up in bed with the head of the bed at a 45 - 60 degree angle. Resident 18's feet were against the foot board. During another observation on 7/10/19 at 10:19 a m., Resident 18 was still in the same bed position with both feet against the foot board. During an observation and interview with certified nursing assistant A (CNA A) on 7/10/19 at 10:25 a.m., CNA A stated there were three CNAs working the hallway and stated she did not reposition Resident 18 that morning. CNA A confirmed Resident 18's feet were against the foot board. During an interview with CNA M on 7/10/19 at 10:32 a.m., CNA M stated she also did not reposition Resident 18 that morning. During an observation and interview with registered nurse C (RN C) on 7/10/19 at 10:35 a.m., RN C inspected Resident 18's feet and stated Resident 18 had a non-blanchable area on the tip of the left great toe. RN C also stated there was also blanchable redness on the tip of the right great toe. During an interview with CNA N on 7/10/19 at 10:40 a.m., CNA N stated she did not reposition Resident 18 and was just placed on the floor to cover another CNA. Review of Resident 18's Minimum Data Set, dated [DATE], indicated Resident 18 needed extensive assistance from the staff with two or more persons physical assistance for bed mobility (how the resident positions body while in bed). Review of Resident 18's activities of daily living (ADL) plan of care dated 3/8/19 indicated Resident 18 required 2 staff participation to reposition and turn in bed. Review of Resident 18's pressure ulcer care plan indicated Resident 18 had a potential for pressure ulcer development due to decreased mobility. It indicated to follow the facility's policy and procedure for prevention and treatment of skin breakdown. Review of Resident 18's active physician's orders for July 2019 printed on 7/9/19 indicated no active orders for wound or skin breakdown. Review of the facility's policy and procedure, Prevention of Pressure Ulcers dated 10/2010, indicated to change position at least every two hours or more frequently if needed for a person in bed. According to the National Pressure Ulcer Advisory Panel (NPUAP) website, a pressure injury occurs as a result of intense and/or prolonged pressure. It indicated a stage one pressure injury was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 9 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 localized area of non-blanchable erythema (redness of the skin that does not become pale when pressure is applied). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 10 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing assistant program (RNA, a program intended to improve or maintain level of functioning) for eight of eighteen sampled residents. 1. For Resident 2, there was no referral for the RNA program. 2. For Resident 54, the facility did not provide appropriate equipment for her left stiff neck and contracted hands. 3. For Residents 1, 15, 18, 37, 44, and 63, the facility made referrals for restorative nursing program for range of motion and exercises but there was no RNA program per facility. These failures could result in residents' further decline in functional abilities. Findings: During an observation on 7/10 /19 at 2:11 p.m., Resident 2 was lying in bed. His hands had contractures (shortening and hardening of muscles, tendons, and other tissues often leading to deformity, and rigidity of joints) and he had bilateral foot drop (difficulty lifting the front part of the foot). During a concurrent interview with Resident 2, he stated the staff used to come and do exercises but they stopped coming about a year and a half ago. He stated he did not remember having hand contractures and bilateral foot drop when he came in 9 years ago. Resident 2 stated he would like to do the exercises again. Review of Resident 2 's clinical record indicated he was admitted on [DATE] with diagnoses to include cerebellar ataxia (a genetic disease that causes progressive loss of coordination and difficulties with balance and gait). Review of his minimum data set (MDS, an assessment tool) dated 3/12/19,indicated he was cognitively intact, and required extensive assistance from staff for his care. He also had impairment of both upper and lower extremities for range of motion (ROM). During a record review and concurrent interview with the MDSC on 7/11/19 at 1:39 p.m., she stated the contracture was noted on 2/6/14 during the quarterly MDS assessment. Resident 2 was on an RNA program sometime during the early part of his stay. The MDSC stated Resident 2 was not on the RNA program since 5/5/18. She stated if there was an actual contracture it would be nursing responsibility to make a referral for a rehabilitation screen (rehab screen) and to call the physician for RNA order based on the rehab screen. Review of the referral list for RNA program did not include Resident 2's name on the list. 2. During the initial tour and observation on 7/8/19 at 10:21 a.m., Resident 54 was lying on her back with her head tilted to her left side and her hands had contractures. There were no equipment to support the left neck and the hand contractures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 11 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm During another observation on 7/8/19 at 4:15 p.m., Resident 54 was lying on her back with the head tilted to her left side, with saliva drooling to her side. During another observation with CNA H on 7/9/19 at 11:19 a.m., Resident 54 was lying on her back with her neck tilted to her left side. Residents Affected - Some During a concurrent interview with CNA H, he stated Resident 54 had a pillow for her neck, but he forgot to put it on since yesterday. He retrieved a neck pillow from the cabinet and placed it underneath the resident's left chin and not around her neck. He also stated they just turned the resident an hour ago but could not remember to which side she was turned. He later acknowledged they did not turn the resident. During an interview with the DSD on 7/9/19 at 8:16 a.m., she stated the resident should be turned at least every 2 hours. She stated they are working on the RNA program and the RNA binder included a list of residents on the RNA program. A review of the list did not include Resident 54's name on it. The DSD stated she would include her name on the list. Review of Resident 54's clinical record indicated she was admitted on [DATE] with the diagnoses to include multiple sclerosis (MS, nerve damage that disrupts communication between the brain and the body). Review of Resident 54's care plan revised on 5/11/19 indicated she had performance deficit related to her mobility, seizure disorder, diabetes (high blood sugar), her MS diagnosis and contractures. The interventions included Provide gentle range of motion as tolerated. There was no interventions for contractures. Review of the facility's revised policy dated 4/13, Restorative Nursing Care, indicated . The facility's restorative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self -care and independence . Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. 3. Review of the facility's Restorative Nursing Program Referral Forms indicated the following: Resident 1 was discharged from the rehabilitation program on 6/29/19. It also indicated Resident 1 was assessed by a physical therapist on 6/28/19 with recommendations for supine (lying down) and seated therapy exercises on both lower extremities due to decreased bed mobility and decreased strength. Resident 15 was discharged from the rehabilitation program on 4/12/19 and was assessed by a physical therapist on 4/15/19 with recommendations to perform the omnicycle (motor-assisted exercise machine for upper and lower extremities) 15 times three times a week for 12 weeks and ambulate with a front wheel walker with minimum assistance due to decreased bilateral lower leg strength and decreased bilateral ambulation. Resident 18 was discharged from the rehabilitation program on 4/15/19 and was assessed by a physical therapist on 4/18/19 with recommendations to perform omnicycle and to ambulate with a front wheel walker due to problems with decreased lower extremity strength and decreased ambulation. Resident 37 was discharged from the rehabilitation program on 3/1/19 and was assessed by the physical therapist on 3/4/19 with recommendations to ambulate in the hallway or level outdoor surfaces. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 12 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some also indicated to do standing hip abductions with cuff weights and perform step ups with contact guard assistance (direct contact with resident while during activity/exercise). It indicated Resident 37 had problems with ambulation and decreased strength. Resident 44 was assessed by the rehabilitation director on 5/7/19 with the recommendation for passive range of motion (PROM, motion at a given joint when the joint is moved by an external force or therapist) to both upper and lower extremities due to decreased range of motion. Resident 63 was discharged from the rehabilitation program on 6/11/19 and was assessed by a physical therapist on 6/13/19 with recommendations for active assisted range of motion (AAROM, exercise in which a manual or mechanical external force assists specific muscles and joints to move through their available excursion) and PROM to both upper and lower extremities due to decreased active range of motion and decreased functional activity. During an interview with certified nursing assistant J (CNA J) on 7/10/19 at 9:03 a.m., CNA J stated she's also trained as restorative nursing assistant (RNA). CNA J stated the facility used to have an RNA program. CNA J stated they perform RNA but not consistently. She further stated the facility continued to receive referrals from the rehabilitation department but not actual physician's orders to perform RNA exercises to the residents. During an telephone interview with the facility's medical director (MS) on 7/12/19 at 9:39 a.m., he stated the RNA program is a nursing-run program. He stated if a resident needed to be in the RNA program, based on nursing assessment and the rehabilitation screen, the staff should call the physician for an RNA order. During a concurrent record review of the QAPI minutes and interview with the administrator (ADM) and the director of nursing (DON) on 07/12/19 at 1:09 p.m., The DON and the ADM stated the facility did not have a restorative nursing program since summer of 2018. The ADM stated restorative nursing assistants (RNA) were being pulled from their RNA duties to perform certified nursing assistant (CNA) duties due to staffing issues and the facility could not fulfill the restorative nursing program orders so the program was removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 13 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure communication sheet and assessment were completed for one of one sampled resident (Resident 77) when dialysis center provided pain medication(tube of 2.5% lidocaine and 2.5% prilocaine) to Resident 77. This failure had the potential misue of the medication by other residents. Residents Affected - Few Findings: During the initial tour and observation on 7/8/19 at 1:30 p.m., there was an opened tube of Lidocaine 2.5% and Prilocaine 2.5% cream (medications for pain) with instructions to apply to affected areas 30-60 minutes before dialysis found on top of Resident 77's bedside table. During a concurrent interview with Resident 77, she stated she applied the cream to her right arm an hour prior to dialysis every Tuesday, Thursday and Saturday. A review of Resident 77's clinical record indicated there was no physician's order for the medication, no care plan and no self-medication assessment done. Review of the facility's December 2012 revised policy, Self- Administration of Medications, indicated Residents can self-administer medications if it determined that they are capable of doing so. The staff and practitioner assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 14 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 3 sampled residents (Residents 8 and 21) were free from unnecessary medications when: Residents Affected - Few 1. Resident 8, on antipsychotic medication (Seroquel) with no specific target behavior monitored related to its use, and no abnormal involuntary movement scale assessment (AIMS - a tool that aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance) test done. 2. Resident 21, on antipsychotic medication (Zyprexa), no AIMS test done. These failures had the potential to result in staff not monitoring the intended target behaviors and not properly evaluating the effectiveness and side effects of the medications. Findings: 1. A review of Resident 8's clinical record indicated she was admitted with diagnoses of Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and, eventually, the ability to carry out the simplest task, dementia (problem with reasoning, memory and judgment) without behavioral disturbance. Resident 8's physician order dated 3/22/19, indicated she was receiving Seroquel (Quetiapine) 50 milligrams (mg, unit of measurement) 1 tablet per day for delusions. Monitor antipsychotic behavior manifested by delusions every shift. During a record review and concurrent interview with the director of nursing (DON) on 7/11/19 at 9:10 a.m., she stated after review of Resident 8's clinical record, she found no AIMS test done. During an interview and concurrent record review with the director of social services (DSS) on 7/11/19 at 8:48 a.m., she confirmed the behavior being monitored in the psychotropic monthly review for Seroquel was delusions. The DSS stated delusions was more of diagnosis and not specific behavior. During a telephone interview with the pharmacy consultant (PC) on 7/11/19 at 1:32 p.m, she stated there should be specific behavior being monitored for the psychotropic medications used for Resident 8. Delusions was not a specific behavior. 2. A review of Resident 21's clinical record indicated admission on [DATE] with diagnosis of dementia with behavioral disturbance., unspecified psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and adjustment disorder with depressed mood. A review of Resident 21's physician's order included Zyprexa (Olanzapine, medication for psychosis) 5 mg by mouth daily for depression, monitor aggressive/threatening behaviors every shift, and Zoloft (sertralinefor depression) 50 mg daily for depression manifested by verbalizing feeling depressed every shift. The AIMS was not completed. During an interview on 7/11/19 at 3:52 p.m., the DON stated the physician's order for Seroquel should have included depression with psychosis. The DON stated the diagnosis was incorrect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 15 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm During a telephone interview with the PC on 7/11/19 at 1:32 p.m., she stated Seroquel was not an antidepressant. A review of the the 2007 facility's policy, Medication Monitoring Medication Management, indicated each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 16 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure the kitchen staff were safely performing their functions, when the dishwasher sanitizer was not being properly monitored. This failure had the potential of inducing food-borne illness. Findings: During an interview with dishwasher E (DWR E) on 7/8/19 at 10:58 a.m., he stated he did not test the sanitizer level, because the detergent/sanitizer control unit, mounted on the wall, lets them know when the sanitizer holder needs to be refilled. During an interview with DWR E on 7/9/19 at 8:26 a.m., he stated he did not check the dishwasher sanitizer amount using test strips. DWR E stated the control unit let them know when the sanitizer needed to be refilled. The facility's undated policy and procedure, Dish Washing, indicated .8. A temperature log (and chlorine log for low-temperature machines) will be kept .This log will be completed each meal prior to any dishwashing.The proper chlorine level is crucial in sanitizing the dishes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 17 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure pureed food was consistently prepared in a manner which conserves its nutritional value, when too much creamer was added to the green beans when being processed into puree. This failure had the potential of vulnerable residents loosing weight from low nutritive value foods. Residents Affected - Some Findings: During an observation and subsequent interview of cook F (CK F) preparing the puree meals on 7/08/19 at 11:02 a.m., CK F placed cooked green beans into the food processor, then added ~1/2 quart of non-dairy creamer, then thickener. He then pureed it and added more creamer. He stated, it was too thick so he added more creamer. During a review of the facility's recipe, French Style [NAME] Beans FZN PU, indicated 1. prepare according to regular recipe. 2. Process until smooth using 1 tsp food thickener per serving.NOTES: 1. Amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 18 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure the kitchen staff was preparing foods in a sanitary way when inadequate hand hygiene practices were being performed while preparing the food. This failure had the potential of inducing food-borne illness. Findings: During an observation on 7/8/19 at 11:14 a.m., cook F (CK F) was observed cutting raw chicken. He then took off his gloves and donned another pair of gloves without hand washing. During an interview with CK F on 7/8/19 at 11:35 a.m., he stated he did not perform hand hygiene after removing gloves used when cutting the raw chicken and prior to donning new gloves. The facility's undated policy and procedure, Infection Control, indicated After completion of the task involving contact with a Resident or with contaminated equipment, gloves are promptly removed and discarded in an appropriate waste container . Gloves do not replace hand washing. Hands are washed following removal of gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 19 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 53's clinical record indicated she was admitted on [DATE] with diagnoses to include Alzheimer's disease (progressive disease that destroys memory and other important mental functions, also known as senile dementia) and Dementia. Her admission record indicated a female friend as her responsible party (RP, a person who is usually legally responsible for the resident's finances) for care conference and the first emergency contact person. Review of Resident 53's physician order summary report (active orders as of 7/9/19) indicated the resident was not capable of understanding or making her own decisions. During a record review and concurrent interview with the assistant director of nursing (ADON) on 7/9/19 at 2:16 p.m., Resident 53 had an unwitnessed fall and sustained an injury. It indicated the facility notified the nurse practitioner (NP, a nurse qualified to treat certain medical conditions without the direct supervision of a physician) and Resident 53 was her own RP. She stated the director of social service (DSS) would be in a better position to explain the role of the female friend as the RP. During an interview with the DSS on 7/9/19 at 3:28 p.m., she stated Resident 53 had no family and her female friend hesitantly agreed to be the resident's RP for care conference and emergency contact. The DSS acknowledged there was no documentation of the female friend's agreement to be Resident 53's RP. She also stated they should discuss the RP situation in the interdisciplinary team meeting (IDT, a meeting of various health care providers to discuss the resident's plan of care) should the RP not be able to carry out her responsibilities as an RP. Review of the facility's revised policy, dated 8/08, Charting and Documentation, indicated .All services provided to the resident, or any changes in the resident's medical or mental condition shall be documented in the resident's medical record . All observations, medications administered, services performed , etc., must be documented in the resident's clinical records .Entries may only be recorded in the resident's clinical record by the licensed personnel (e.g. RN, LVN, physician) in accordance with state law and facility policy. Based on observation, interview and record review the facility failed to ensure clinical records were complete and accurately documented for two of two sampled residents (63 and 53) when: 1. The physician's orders did not accurately reflect Resident 63's current activity level, decision making, and social activity participation levels and 2. Inconsistency in Resident 53's clinical record as to who was the responsible party (RP, usually the person who is managing the resident's money). These failures could potentially result in incomplete or inaccurate data necessary to assess and meet the residents' needs. Findings: 1. Review of Resident 63's order summary report printed on 7/9/19 at 3:16 p.m. indicated orders on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 20 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 5/19/19. Resident 63 was not capable of understanding or making his own decisions and Resident 63's activity level was at bedrest (confinement to bed as part of treatment). It also indicated Resident 63 may not participate in social activities. During a concurrent record review and interview with the assistant director of nursing (ADON) on 7/11/19 at 2:13 p.m., The ADON stated she checks the physician's orders monthly and missed the errors in Resident 63's physician's orders. The ADON stated Resident 63 was not on bedrest, may participate in social activities and was his own responsible party. Event ID: Facility ID: 056055 If continuation sheet Page 21 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility's Quality Assessment Performance Improvement (QAPI) committee failed to address, develop, and implement plans of action to address the lack of provision of restorative nursing services. Findings: During an interview with Resident 2 on 7/10/19 at 2:11 p.m., he stated the staff used to come and do exercises with him but they stopped coming about a year and a half ago. He stated he did not remember having hand contractures and bilateral foot drop when he came in 9 years ago. Resident 2 stated he would like to do the exercises again. During an interview with Resident 63 on 7/8/19 at 9:53 a.m, Resident 63 stated he would like to do more exercises and has asked for more exercises but was told the staff did not have time. During an interview with certified nursing assistant J (CNA J) on 7/10/19 at 9:40 a.m., CNA J stated she was also trained as restorative nursing assistant (RNA). CNA J stated the facility used to have an RNA program. CNA J stated they still perform RNA but not consistently. CNA J stated the facilitycontinued to receive referrals from the rehabilitation department but not actual physician's orders to perform RNA exercises to the residents. During a telephone interview with the facility's medical director (MD) on 7/12/19 at 9:39 a.m., he stated the RNA program is a nursing-run program. He stated if a resident needed to be in the RNA program, based on a nursing assessment and the rehabilitation screen, the staff should call the physician for an RNA order. During a concurrent record review of the QAPI minutes and interview with the administrator (ADM) and the director of nursing (DON) on 07/12/19 at 1:09 p.m., the DON and the ADM stated the facility did not have a restorative nursing program since summer of 2018. The ADM stated there was no committee minutes addressing the lack of restorative nursing services in the facility. The ADM stated restorative nursing assistants (RNA) were being pulled from their RNA duties to perform certified nursing assistant (CNA) duties due to staffing issues and the facility could not fulfill the restorative nursing program orders so the program was removed. The ADM stated the director of rehabilitation recommended a home exercise program to replace the restorative nursing program but there was no committee minutes indicating how to implement the program and how to track or monitor the effectiveness of the program. Review of the facility's 2019 Carmel Hills QAPI Plan, indicated the purpose of the QAPI is to proactively seek out improvements made within their facility to increase the professional standard levels of care they provide to residents. It indicated they would utilize the SMART formula to address problems to be solved. It indicated the facility would have a specific goal that is measurable, attainable, relevant, and time bound for systems issues in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 22 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During the initial tour on 7/8/19 at 8:20 a.m., Resident 36 was in an isolation room. There was no visible signage on the entrance door that would alert personnel and visitors of infection precautions needed prior to entering the room. There was an isolation cart by the entrance door. Residents Affected - Few Review of Resident 36's clinical record indicated she was admitted on [DATE] for gastrointestinal bleeding, anemia (low blood count), respiratory failure, and stroke. She was placed on C.Diff.(inflammation of the colon caused by the bacteria Clostridium defficile) isolation on 6/24/19 and currently treated with antibiotic. During an interview with registered nurse L (RN L) on 7/8/19 at 12:30 p.m., she stated Resident 36 was on C.Diff. isolation. She stated there was a sign to wear a gown, mask, and gloves when entering the room. (The sign was hidden behind two boxes of isolation masks on top of the cart). She confirmed there should be a sign to do handwashing after encounter and care of resident, and a sign to alert visitors to check with the nurse prior to entering the resident's room. During an interview with director of staff development (DSD) on 7/10/19 at 7:59 a.m., she stated Resident 36 had history of C.Diff. She acknowledged there should be have been an appropriate signage on the entrance door. Review of the facility's revised policy dated 4/12, Isolation-Initiating Transmission Based Precautions, indicated . the Infection Control Preventionist shall .Post the appropriate notice on the entrance door and on the front of the resident's chart so all personnel will be aware of precautions, or be aware that they must first see the nurse to obtain additional information about the situation before entering the room. Based on observation, interview and record review, the facility failed to ensure staff implemented infection control procedures when: 1. Two residents (Residents 1 and 10 ) who had episodes of infections were not included in the infection surveillance; 2. Three staff members did not wash their hands before entering the room and after leaving the room of one resident (Resident 1) on isolation precautions per facility's isolation procedures; 3. There was no signage on entrance door indicating to alert personnel and visitors of added precautions. These failures had the potential to result in transmission of infection in the facility. Findings: 1a. Review of Resident 1's physician's orders indicated Resident 1 had an order dated 6/12/19 and 6/25/19 for ciprodex (an antibiotic) 0.3-0.1 percent (%) five drops to the right ear twice a day for 7 days for ear infection. Resident 1 also had an order dated 6/13/19 for levaquin (an antibiotic) once a day for 8 days for pneumonia (infection of the lungs) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 23 of 24 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056055 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carmel Hills Care Center 23795 W. R. Holman Highway Monterey, CA 93940 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's Line Listing of Resident Infections for May 2019 and June 2019, did not indicate Resident 1's infections or use of antibiotics. During a concurrent record review and interview with the director of staff development (DSD) on 7/12/19 at 9:39 a.m., the DSD confirmed Resident 1 was not included in facility's infection surveillance for May 2019 and June 2019. During a concurrent record review and interview with the DSD on 7/12/19 at 9:39 a.m., the DSD confirmed Resident 1 was not included in the infection surveillance for May and June 2019. 1b. Review of Resident 10's physician's orders indicated Resident 10 had an order dated 2/20/19 for Bactrim DS (an antibiotic) 800 - 160 milligrams (mg, a unit of measurement) twice a day for 10 days for urinary tract infection (UTI, an infection of the bladder and kidneys) and an order dated 3/5/19 for Gentamicin 160 mg once a day for four days for UTI. Review of the facility's Line Listing of Resident Infections for February 2019 and March 2019, did not indicate Resident 10's infections or use of antibiotics. During a concurrent record review and interview with the DSD on 7/12/19 at 10:03 a.m., DSD confirmed Resident 10 was not included in the infection surveillance for February and March 2019. Review of the facility's undated policy, Infection Control Nurse, indicated the facility would perform a surveillance to identify residents with infections and monitor antibiotic use.2. During an observation and concurrent interview on 7/9/19 at 9:02 a.m., certified nursing assistant H (CNA H) entered Resident 1's room who was on contact isolation precautions for methycillin resistant staphyloccocus aureus (MRSA, an antibiotic resistant infection) infection of nares (nose) without washing his hands before donning gloves and after removing his gloves before leaving the resident's room. CNA H stated he should have washed his hands before entering and after leaving Resident 1's room. During an observation on 7/9/19 at 9:19 a.m. a housekeeper (HK) and certified nursing assistant I (CNA I) entered Resident 1's room without washing their hands before entering the room. During an interview on 7/9/19 at 9:29 a.m., CNA I, confirmed and read the signage posted by the door of Resident 1's room that indicated: Contact precautions: Wash hands with soap and water before entering and after leaving the room. Do not use an alcohol hand rub. CNA I confirmed that both he and the HK did not wash their hands as indicated in the signage posted. CNA I answered room [ROOM NUMBER]'s call light just after coming out of Resident 1's room without washing his hands. He stated, he should have washed his hands. A review of the facility's undated policy, Infection Control Overview, indicated the facility is concerned with preventing the development and spread of infections. It is the responsibility of all employees to know and practice infection prevention and control measures. The most effective means of combating infection is correct hand hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056055 If continuation sheet Page 24 of 24